SAPHO syndrome masquerading as metastatic bone disease.

A 46-year-old woman who had had a right mastectomy for breast carcinoma a month before underwent bone scintigraphy. The examination revealed multiple pelvic, vertebral and sternal hot spots suggestive of bone metastases. Standard X-rays and CT confirmed the presence of bony lesions but they were not typical of bone metastases. As the radiographic appearance was reminiscent of SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), bone biopsies were performed. Histology showed fibrosis and hyperostosis but no tumour cells. On further questioning, the patient revealed she had had palmar pustulosis and sacroiliitis some years earlier. The purpose of the case report is to show that accurate diagnosis of SAPHO syndrome requires careful clinical and radiological examinations.

Paranasal sinuses in children: size evaluation of maxillary, sphenoid, and frontal sinuses by magnetic resonance imaging and proposal of volume index percentile curves.

Our objective was to establish the age-related 3D size of maxillary, sphenoid, and frontal sinuses. A total of 179 magnetic resonance imaging (MRI) of children under 17 years (76 females, 103 males) were included and sinuses were measured in the three axes. Maxillary sinuses measured at birth (mean+/-standard deviation) 7.3+/-2.7 mm length (or antero-posterior)/4.0+/-0.9 mm height (or cranio-caudal)/2.7+/-0.8 mm width (or transverse). At 16 years old, maxillary sinus measured 38.8+/-3.5 mm/36.3+/-6.2 mm/27.5+/-4.2 mm. Sphenoid sinus pneumatization starts in the third year of life after conversion from red to fatty marrow with mean values of 5.8+/-1.4 mm/8.0+/-2.3 mm/5.8+/-1.0 mm. Pneumatization progresses gradually to reach at 16 years 23.0+/-4.5 mm/22.6+/-5.8 mm/12.8+/-3.1 mm. Frontal sinuses present a wide variation in size and most of the time are not valuable with routine head MRI techniques. They are not aerated before the age of 6 years. Frontal sinuses dimensions at 16 years were 12.8+/-5.0 mm/21.9+/-8.4 mm/24.5+/-13.3 mm. A sinus volume index (SVI) of maxillary and sphenoid sinus was computed using a simplified ellipsoid volume formula, and a table with SVI according to age with percentile variations is proposed for easy clinical application. Percentile curves of maxillary and sphenoid sinuses are presented to provide a basis for objective determination of sinus size and volume during development. These data are applicable to other techniques such as conventional X-ray and CT scan.

Is cisplatin required for the treatment of non-small-cell lung cancer? Experience and preliminary results of a phase I/II trial with topotecan and vinorelbine.

Platinum-based chemotherapy is considered standard treatment for advanced non-small-cell lung cancer (NSCLC). However, toxicity of most platinum-based regimens is substantial and requires close monitoring and supportive care. Over the past decade, paclitaxel, docetaxel, vinorelbine, gemcitabine, irinotecan, and topotecan have been introduced into the clinic. These newer agents have shown promising activity against NSCLC with a favorable toxicity profile as single agents. For patients with metastatic NSCLC, palliation is the main goal of therapy. Therefore, treatment should be easy to administer on an outpatient basis. We explored a novel combination therapy avoiding platinum. Patients with recurrent or metastatic NSCLC were treated with intravenous (i.v.) topotecan (0.5-1.0 mg/m(2)/day x 5) and i.v. vinorelbine (20-30 mg/m(2)/day on day 1 and day 5) in 21-day cycles. Dose-limiting toxicity (DLT) was defined separately with or without the addition of granulocyte colony-stimulating factor (G-CSF) support. Twenty-nine patients have been enrolled to date. At i.v. topotecan doses of 0.75-1.0 mg/m(2)/day and i.v. vinorelbine of 25 mg/m(2)/day, neutropenia was frequent but of short duration (<7 days). The DLT of i.v. topotecan (0.85 mg/m(2)) in the absence of G-CSF support was based on myelosuppression with neutropenic fever. With the addition of G-CSF, a DLT has not been reached. Nonhematologic toxicities included mild to moderate fatigue and constipation. An overall clinical response rate of 42% was achieved, with responses noted at all dose levels. At a short median follow-up of 15 months, the median survival for all patients is 13 months. In conclusion, the combination regimen of topotecan and vinorelbine is feasible for outpatient administration and is well tolerated with less toxicity than platinum-based regimens. Preliminary response data demonstrate good tumor activity, suggesting that this regimen could make an excellent palliative treatment for advanced NSCLC.

2D and 3D CT imaging correlated to rigid endoscopy in complex laryngo-tracheal stenoses.

The aim of this study was to compare 2D and 3D CT imaging in the pre- and postoperative evaluation of complex benign larynges-tracheal airway stenoses with rigid endoscopy, considered as the gold standard. Six patients (aged 5-72 years) with a total of nine complex laryngo-tracheal stenoses underwent non-contrast helical CT scans (slice thickness 3 mm, pitch 1.3, reconstruction interval 1.5 mm) before and after surgical resection. With prototype software, virtual endoscopy (VE) post-processing algorithms were applied to the imaging data sets. The VE and multiplanar 2D findings were compared with rigid endoscopy, considered as standard of reference. All nine stenoses were correctly identified on 3D images and their anatomical locations correctly assessed on 2D reconstructions. Artifacts were met when patients were unable to suspend their breath, leading to one false-positive result. Two-dimensional images and 3D VE of tracheal stenoses proved to be efficient and complementary to the rigid endoscopy, permitting a reliable endoluminal 3D view and evaluation of the surrounding anatomical structures. Limitations of this technique relate to the maximal spatial resolution of 1.5 mm, the lack of color, and the inability to assess the mucosa. Virtual endoscopy is for complex laryngo-tracheal stenoses an excellent complement for rigid endoscopy, remaining the method of reference, and may be indicated with complicated pathological structures.

Diagnostic accuracy and interobserver agreement of CT colonography (virtual colonoscopy).

BACKGROUND AND AIMS: Computed tomographic (CT) colonography or virtual colonoscopy (VC) is a non-invasive imaging method proposed for screening patients with colorectal neoplasias. Our aims were to study the diagnostic accuracy and interobserver agreement of VC for correct patient identification compared with conventional colonoscopy (CC). METHODS: This was a prospective study of 50 patients successively undergoing VC and CC. Multiplanar two dimensional CT images and three dimensional VC were constructed using surface rendering software and interpreted by two independent investigator teams. VC findings were compared with those of CC. Interobserver agreement was determined using kappa statistics. RESULTS: CC found 65 polyps in 24 patients. For identification of patients with polyps > or =10 mm, the sensitivity of VC was 38% and 63%, and specificity was 74% and 74% for teams 1 and team 2. Interobserver agreement was good (kappa 0.72). For patients with polyps of any size, the sensitivity of VC was 75% and 71%, and specificity was 62% and 69% for teams 1 and 2. Interobserver agreement was fair (kappa 0.56). Accuracy improved when comparing the results of the first 24 with the last 26 patients. CONCLUSIONS: In our experience, VC had a low diagnostic value for identification of patients with colorectal neoplasias. Interobserver agreement for VC interpretation was fair. These results may be explained by software imperfections and a learning curve effect.

[Prognostic aspects of scintigraphy and MRI during the first 6 months of reflex sympathetic dystrophy of the distal lower limb: a preliminary prospective study of 4 cases]. / Evolution de l'imagerie scintigraphique et IRM au cours des 6 premiers mois d'une algoneurodystrophie distale des membres inférieurs: étude préliminaire prospective de 4 cas.

PURPOSE: The appearance of scintigraphic and magnetic resonance imaging during the evolution of reflex sympathetic dystrophy of the foot is not well known and subject to controversies. The purpose of this preliminary study is to compare these two types of investigation during the first 6 months of evolution. METHODS: 4 non-selected patients with a diagnosis of acute reflex sympathetic dystrophy of the foot (no more than 2 months of evolution and more than 3 out of 6 clinical criteria suggesting a "warm" phase) were studied prospectively. A clinical evaluation, scintigraphy and magnetic resonance imaging (MRI) were performed at diagnosis and after 3 and 6 months. All available examinations (n = 22) were analyzed independently by independent observers. RESULTS: Clinically 3 of 4 patients developed or previously had another site of sympathetic dystrophy confirmed by total body scintigraphy. After 6 months 2 of 4 patients still have a "warm" dystrophy. Bone scanning showed localized or diffuse tracer uptake and MRI showed bone and soft tissue edema when the sympathetic dystrophy was and/or remained clinically "warm". MRI bone edema moved from one location to another in 3 of 4 patients during the follow-up. There was a good correlation between bone scan and MRI images. In "warm" dystrophy, MRI was positive 5 out of 7 times and scintigraphy in all cases. Bone edema and tracer uptake faded simultaneously although the latter was more diffuse and more persistent than the former. CONCLUSION: MRI as well as bone scintigraphy are suitable for the diagnosis of warm dystrophy of the foot. Both exams remain positive when the dystrophy is still "warm" after 6 months. The radiographic evolution after 6 months still has to be evaluated.

Localization of static positional nystagmus with the ocular fixation test.

OBJECTIVE: Characteristics of static positional nystagmus (SPN) (i.e., persistency, direction fixed, direction changing) are observed in both peripheral and central disturbances and possess no localizing value for vestibular lesions. Our objective was to investigate whether the ocular fixation test as applied to SPN could assist in localizing vestibular lesions. STUDY DESIGN: A 3-year prospective study that included 43 patients with SPN. METHODS: All patients underwent a standard vestibular test battery and cerebral imaging (7, computed tomography scan; 36, magnetic resonance imaging). The ocular fixation index (OFI) was calculated by the ratio of the mean slow component velocity of SPN (measured with red light-emitting diode fixation) to that measured in darkness, multiplied by 100. An OFI less than 50 was considered normal. RESULTS: In 33 of 35 patients whose OFI was less than 50, the cerebral imaging was normal and a peripheral vestibular lesion was diagnosed (two benign tumors of the fourth ventricle were missed). In all eight patients whose OFI was greater than 50, the cerebral imaging was abnormal and a central vestibular lesion was noted. CONCLUSIONS: These results indicate that the visual suppression of SPN does, indeed, permit the localization of vestibular lesions. The predictive value of the ocular fixation test on the origin of SPN is greater than 94% for peripheral lesions and 100% for central disorders.

Imaging of the normal and pathological orbit.

Computerized techniques (CT and MRI) allow precise delineation of orbital anatomy and abnormalities. Orbital tumors are nicely depicted by these methods; various examples are illustrated in this article, with discussion of the respective impact of CT and MRI. Orbital inflammation and foreign bodies usually represent radiologic emergencies, prompting use of CT (frequently) or MRI (occasionally). Digital subtraction angiography (DSA) is indicated for diagnosis of vascular changes (mainly carotid-cavernous fistula, aneurysms, angiomas, Rendu-Osler disease). Angiography is usually done to ascertain the possibility of an interventional procedure. Orbital vascular interventions include re-canalization of occluded vessels, and embolization of pathologic (tumorous or post-traumatic) vessels.

[Influence of naso-sinusal anatomic variants on recurrent, persistent or chronic sinusitis. X-ray computed tomographic evaluation in 112 patients]. / Influence des variantes anatomiques nasosinusales sur les sinusites récidivantes, persistantes ou chroniques. Evaluation TDM chez 112 patients.

Using CT scan, we studied the influence of the most important sinonasal anatomic variants on 112 patients, aged more than 16 years, suffering from recurrent, persistent or chronic sinusitis. The series was characterized by the absence of: multifocal sinusitis, polyposis, dental or mycotic sinusitis, traumatic, tumour, actinic or prior surgery. We compared our results with those of the literature. Our findings confirmed the association between recurrent, persistent or chronic sinusitis, and ipsilateral septal ridges or spurs (33%), unusual ipsilateral deflexions of uncinate process (31%), and contralateral septal watch glass like deviation (42%). We found no correlation for the other studied variants (concha bullosa, paradoxical curve of middle turbinate, pneumatised uncinate process, hypertrophic ethmoid bulla, Haller cell and accessory maxillary ostium).

Enthesopathy and tendinopathy in gout: computed tomographic assessment.

OBJECTIVE: To establish if computed tomography (CT) imaging, which has proved helpful in detecting intra-articular tophi in gout, can also be used to document gouty enthesopathy and tendinopathy. METHODS: Three patients with tophaceous gout and clinical involvement of the Achilles tendon (two cases) or patellar tendon (one case) were assessed with CT examination and plain radiographs. RESULTS: In the first two cases, CT images revealed linear or nodular high attenuation opacities within the substance of the Achilles tendons and their calcaneal insertion. In case 3, dense linear opacities were seen within the patellar tendon and within its tibial insertion. No such opacities of the tendons and entheses were seen on standard radiographs of these patients. CONCLUSIONS: CT appears to be the imaging method of choice for demonstrating monosodium urate deposits in entheses and tendons in tophaceous gout.

Computed tomography of the knee joint as an indicator of intraarticular tophi in gout.

OBJECTIVE: To evaluate the utility of computed tomography (CT) of the knee joint for detecting intraarticular tophaceous deposits. METHODS: A prospective study of 16 patients with gout affecting the knee was conducted. A condition for inclusion in the study was the presence of needle-shaped crystals with negative birefringence in the knee joint synovial fluid. Conventional radiography and CT were performed in each case. RESULTS: Intraarticular opacities in the capsule and the synovium, consistent with the presence of tophaceous deposits, were found in 5 of the 16 patients (9 knee joints). The mean duration of gout was longer in the patients with intraarticular tophi than in those without tophi, and 2 of the patients with tophi had poor tolerance to antihyperuricemic therapy. CONCLUSION: Intraarticular opacities considered to represent tophi were observed in approximately one-third of the patients. The presence of tophi correlated with a longer duration of the disease and a poor tolerance to medication. We therefore suggest that CT of the knees could be useful in the assessment and followup of certain patients with gout.

Traumatic chest lesions in patients with severe head trauma: a comparative study with computed tomography and conventional chest roentgenograms.

In patients with severe craniocerebral trauma, who need a continuous positive-pressure breathing, the detection of pulmonary and mediastinal traumatic lesions, especially pneumothorax, may alter the management. The aim of this study is to evaluate the efficiency and accuracy of conventional supine chest roentgenograms to detect the associated traumatic chest lesions in severe craniocerebral trauma and to compare their value as a diagnostic method for the identification of unsuspected lesions with a limited chest computed tomographic (CT) examination. Forty-seven consecutive patients with severe craniocerebral trauma underwent head CT and a prospective limited CT examination of the thorax in the same session. Nine patients (19.1%) presented a pneumothorax, bilateral in one case. Six pneumothoraces (60%) were identified both on conventional chest roentgenograms and CT, whereas in four cases (40%), the lesion was only detectable on CT. The CT study also showed 31 areas of pulmonary parenchymal contusions in 19 subjects (40%), whereas the conventional chest roentgenograms demonstrated 17 areas of contusions in 11 (23%) subjects. One thoracic aorta and one right diaphragm rupture were detected on CT study. On the conventional chest roentgenograms the mediastinal vascular injury was overlooked, whereas the right diaphragmatic rupture was highly suspected. The limited chest CT examination supplied additional information in 30% of patients. In 12.7% of patients, this information was clinically significant enough to alter the management. In patients with severe craniocerebral trauma evaluation of associated chest trauma by a supplementary limited chest CT, examination provides more and precise information about the size and severity of mediastinal and pulmonary lesions with a superior detectability of pneumothorax.

Concha bullosa: frequency and appearances on CT and correlations with sinus disease in 308 patients with chronic sinusitis.

The purposes of this study were to determine the prevalence of concha bullosa in patients with chronic sinusitis, to assess the origin of the pneumatisation (from the anterior or posterior ethmoid cells), and to evaluate the significance of the concha bullosa in the genesis of inflammatory sinus disease. We reviewed the CT studies of 308 patients with chronic sinusitis, assigning four grades of pneumatisation: absent, small, medium and large. Unilateral or bilateral concha bullosa was found in 164 patients (53%). In 79% of cases it was pneumatised via the posterior ethmoidal cells and in 21% via the anterior. A small concha bullosa was associated with abnormalities of the maxillary sinus, ethmoidal cells and ostiomeatal unit respectively in 49%, 28% and 34% of cases, whereas with a large concha bullosa the association was 55%, 36% and 41% respectively on the ipsilateral side and 55%, 32% and 41% on the contralateral side. The usually accepted hypothesis that the concha bullosa may contribute to the pathogenesis of inflammatory sinus disease seems doubtful.

Imaging of cervico-thoracic lymphangiomas in children.

This study was undertaken to define the role of ultrasound (US) and magnetic resonance (MR) imaging in the diagnosis and preoperative staging of cervico-thoracic lymphangiomas in children. In a retrospective study, 11 patients with surgically and pathologically proved lymphangiomas had MR imaging and 6 of them underwent simultaneous US. US showed superficial hypoechogenic multioccular cystic masses with septa of variable thickness, but failed to demonstrate retropharyngeal, axillary or mediastinal extensions in all patients. All lesions were identified on both MR T1-weighted images (T1WI) and T2-weighted images (T2WI). T2WI provided the best tissue contrast between the lymphangiomas and surrounding tissues. T1WI after i.v. injection of gadolinium DOTA (Gd DOTA) in two patients provided additional information regarding the extent of the lesion. The authors concluded that although lymphangiomas have a distinctive sonographic appearance, MR imaging allowed a better tissue characterisation and tumour extent. T2WI and T1WI after i.v. injection of Gd DOTA are especially helpful for the diagnosis and preoperative staging of cervico-thoracic lymphangiomas in children.

[Magnetic resonance imaging and x-ray computed tomography in advanced cancer of the oral cavity. A comparative clinical, radiological and morphological study]. / Apport de l'imagerie par résonance magnétique et de la tomodensitométrie dans les cancers avancés de la cavité buccale. Etude comparative clinique, radiologique, morphologique.

The objective of this prospective study is to assess the impact of magnetic resonance imaging (MRI) and computed tomography (CT) as compared to physical examination in the choice of type of surgery for advanced intraoral cancers (with or without resection of the mandibula). From 1990 to 1993, we operated on 21 intraoral malignant tumors with segmental resection of the mandibula followed by a histological examination. The preoperative evaluation consisted of an MRI (n = 8), a CT (n = 8) or both (n = 5). MRI suspected an infiltration of the bone in 9 cases, CT in 4 and physical examination in 16. This was histologically confirmed in 6 of the 21 patients only. MRI and CT both have a high sensitivity, as does physical examination, but neither have a good specificity (physical examination: 5 true positive, 4 true negative, 11 false positive, 1 false negative; MRI: 4 true positive, 4 true negative, 5 false positive, 0 false negative; CT: 3 true positive, 7 true negative, 3 false positive, 0 false negative). In conclusion, the decision of a mandibular resection can only be taken after a careful physical examination, including palpation under general anesthesia in a fully relaxed patient. This is best accomplished during the pretherapy bronchoesophagoscopy, routinely performed for the detection of synchronous second primary tumors using toluidin blue as a vital staining method. If this initial evaluation gives a suspicion of a massive infiltration of the mandible, an MRI, rather than a CT, should be performed to determine the extent of the resection because of a high rate of artefacts with CT.